Why the CQC could inadvertently threaten NHS funding

Ted Baker, the chief inspector of hospitals, recently presented the latest Care Quality Commission inspection results to trust chief executives at a meeting organised by NHS Improvement and NHS England. His overall conclusion was that quality at NHS trusts was improving.

Yes, improving. Not “holding up”, not “declining slightly under enormous pressure” and certainly not “in crisis”. Even the quality of emergency services is, according the inspectorate’s work, not getting worse.

There are examples where standards have slipped, and quality remains, in the words of the last State of Care report, “precarious”, but on balance aggregated inspections show services are performing better now than they were a year or two ago.

The Treasury remains highly sceptical of the NHS’s need for new cash and it required the intervention of the PM to bring it into line

Of course, the first response to the CQC’s findings must and should be to congratulate the NHS leaders and their teams who delivered this improvement in the face of a perfect storm of rising demand and slowing investment. It is also a reminder that for every local newspaper headline declaring the meltdown of its neighbourhood A&E, there is another carrying a feature on the quiet success being achieved by another trust. Variability in NHS quality hides good as well as bad stories.

But it is worth asking why there is such dissonance between the aggregated CQC inspection results and a situation in which access to care is hitting levels not seen for a decade and the media is full of tales of NHS woe.

There are a range of possible explanations.

It could be that:

The NHS is dealing well the current pressures and that the dire reports of collapsing service standards are simply special pleading.

Easily measured standards such as access times get more attention and the CQC’s more nuanced and subjective view of service quality produces a different picture…

Service quality is being held up through the superhuman efforts of staff and the CQC’s inspection process is not sensitive enough to detect that a tipping point is rapidly approaching.

This “blind spot” may have been created by the brief postponement of routine CQC inspections during the height of winter pressures.

CQC inspections only reflect the quality of care of people who receive treatment – not those who remain untreated. This is especially true in mental health – where, for example, only a third of children and young people are getting the care they need.

The real difficulties lie in system working and the relationships between organisations, which are not given enough focus in CQC inspections.

What gets measured gets done and the CQC has now been rigorously measuring trusts for a few years. In other words, trusts focus on meeting the CQC’s regime rather than a broader definition of quality.

Why does it matter?

It is – to say the least – an awkward fact that the NHS’s quality regulator is reporting rising quality standards in the NHS provider sector right now.

The NHS is going to get more money for its 70th birthday this July – that now seems certain. The important questions to ask now are: how much, for how long, when will it arrive, and what for?

The Treasury remains highly sceptical of the NHS’s need for substantial new cash and as HSJ has noted, it required the intervention of the prime minister to bring it into line. Philip Hammond faces demands from many sectors – a significant number with better evidence of the need for higher funding than the NHS, especially its provider sector. The chancellor is going to want those arguing for a historic settlement for the NHS to prove every claim.

Senior figures at the Department of Health and Social Care and NHS England have made the point forcibly and repeatedly to HSJ that being able to refer to the picture painted by the CQC in negotiations with the Treasury is among their most powerful levers.

CQC inspections offer ammunition for both sides of the negotiation. When it comes to boosting spend on the provider sector, the Treasury will no doubt draw attention to trusts which have improved their ratings despite facing the same difficulties as others; and remind Jeremy Hunt of his recent letter to Conservative MPs, in which he declared: “As Conservatives we understand… that funding of our public services is only ever part of the answer to driving up standards.”

It may simply be that CQC inspections are not – and never will be – a guide to overall NHS quality

It may be that political considerations trump any debate over service quality, and the size of the service’s windfall is mandated on the basis that it at least equals anything the opposition would offer and is sufficient to end the avalanche of negative headlines.

But that is a big maybe.

And then there is the credibility of the CQC, which it has worked hard to establish. Imagine Professor Baker appearing on Today to report that quality of care in the NHS provider sector is still, on average and with many caveats, improving.

This may – at heart – be an issue of optics. It may simply be that CQC inspections are not – and never will be – a guide to overall NHS quality. But that seems both a counsel of despair and an acknowledgment that the inspectorate is disconnected from the service’s lived reality.

The CQC is conducting interviews for a new chief executive as this editorial is written, and continuing to refine the inspection model should be high on its agenda.